magnetic resonance imaging spectrum of degenerative
TRANSCRIPT
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International Journal of Orthopaedics Sciences 2020; 6(3): 81-89
E-ISSN: 2395-1958
P-ISSN: 2706-6630
IJOS 2020; 6(3): 81-89
© 2020 IJOS
www.orthopaper.com
Received: 18-05-2020
Accepted: 20-06-2020
Dr. Saryu Gupta
Associate Professor, Department
of Radiodiagnosis, Government
Medical College and Rajindra
Hospital, Patiala, Punjab, India
Dr. Jaswinder Kaur Mohi
Associate Professor, Department
of Radiodiagnosis, Government
Medical College and Rajindra
Hospital, Patiala, Punjab, India
Dr. Puneet Gambhir
Assistant Professor, Department
of Community Medicine,
Government Medical College and
Rajindra Hospital, Patiala,
Punjab, India
Corresponding Author:
Dr. Puneet Gambhir
Assistant Professor, Department
of Community Medicine,
Government Medical College and
Rajindra Hospital, Patiala,
Punjab, India
Magnetic resonance imaging spectrum of degenerative
disease of the lumbosacral spine: A single institution
retrospective cross-sectional observational study
Dr. Saryu Gupta, Dr. Jaswinder Kaur Mohi and Dr. Puneet Gambhir
DOI: https://doi.org/10.22271/ortho.2020.v6.i3b.2182
Abstract Background: Degenerative Disease of the Lumbosacral spine is a leading cause of back ache and
radiculopathy with significant medical and socioeconomic importance. Its pathogenesis represents a
biomechanically related continuum of temporally evolving alterations which are identifiable on various
imaging modalities. Due to its excellent soft tissue contrast, multiplanar capabilities and non-ionizing
nature MRI is indispensable for detailed morphological evaluation of all components of the Functional
Spinal Unit (FSU). It facilitates optimal assessment of the burden of disease thereby guiding
prognostication as well as subsequent therapy and rehabilitation.
Materials and methods: This study is a retrospective cross-sectional observational study whereby MRI
findings ascribed to Degenerative Disease of the Lumbosacral Spine were analysed in 100 patients
fulfilling the inclusion and exclusion criteria.
Results: The mean age of the study participants was 51 years ± 14 years with Male: Female ratio of
1.9:1. The L4-L5 intervertebral disc was the most frequently as well as most severely involved level
irrespective of age and gender of the study subjects. Disc degeneration was the commonest manifestation
seen (100%) followed by nerve root compression (74%), spinal canal stenosis (67%), disc herniation
(64%), facetal arthropathy (41%), bulging discs (38%), ligamentum flavum hypertrophy (34%) and
Modic endplate degenerative changes (31%) in decreasing order of frequency.
Conclusion: MRI is the modality of choice for evaluation of Degenerative Disease of the Lumbosacral
Spine and allows most precise assessment of central spinal canal stenosis. It is hence recommended as
mandatory in the radiological work up of all patients with the chief complaint of low back pain
irrespective of the presence or absence of radiculopathy and / or neurological deficit.
Keywords: Lumbosacral spine, MRI, Disc degeneration, facetal arthropathy, ligamentum flavum
hypertrophy, central spinal canal stenosis
Introduction
Degenerative Disease of the Lumbosacral Spine is the commonest cause of low back pain
worldwide irrespective of age & gender and hence a common referral to the radiologist [1, 2]. In
such cases, conventional spine radiography has often been the initial radiological investigation
followed by NCCT evaluation. However, these often underestimate the quantum of disease
both in terms of extent and severity. MRI by virtue of its non-ionizing character, unparalleled
soft tissue contrast and excellent multiplanar capabilities scores over and above both these
conventional modalities [3]. It particularly enables direct visualization of the soft tissue
components of the spinal column and hence pinpoints the precise relationship between the
herniating disc and the regional nervous structures (nerve roots and spinal cord) as well as
intervertebral foramina [2]. Thereby it facilitates an in-depth review of both the static as well as
the dynamic causative agents for Spinal Degenerative Disease. Additional benefits include a
holistic view of the entire vertebral column on the whole spine screening sequence which
further contributes to the diagnostic yield [2, 3].
Material and methods
Study Design: The present study was carried out in the Department of Radiodiagnosis of
Government Medical College and Rajindra Hospital, Patiala (Punjab). It is a retrospective
cross-sectional observational study of two months duration.
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International Journal of Orthopaedics Sciences www.orthopaper.com All patients referred with the chief complaint of low back pain
& with findings ascribed exclusively to Degenerative Disease
of the Spine on subsequent MRI were included in the study. A
total of 100 such patients fulfilling the inclusion and
exclusion criteria were enrolled in the present study.
Inclusion Criteria: Patients with history of low back pain
with or without radiculopathy or neurological symptoms and
with imaging features of Degenerative Disease of the
Lumbosacral Spine as the sole pathology on the subsequent
Dedicated MRI examination.
Exclusion Criteria: Patients with history as detailed above
but with concurrent history/manifestations of prior spine
surgery, spinal fractures, metabolic bone disease, spinal
infectious pathologies, malignancy, Ankylosing Spondylitis
or Fluorosis.
Procedure: A non – contrast Multiplanar and Multi-sequence
Evaluation was done on a 1.5 T SIEMENS MAGNETOM
Aera Platform in non-weight bearing position using an 18-
channel body coil. The region of interest included Dorsal
vertebra 12 (D12) to S1 sacral segment using predetermined
parameters. The images were acquired as conventional T1
TSE and T2 TSE weighted in axial and sagittal planes, T1
STIR in sagittal and coronal planes as well as T2 TIRM COR
sequences. Additional series were also carried out to generate
a Whole Spine Sagittal Screening Image. All cases were
independently reviewed by an experienced radiologist.
Statistical Analysis
Data entry and analysis was done on Microsoft Office Excel
version 2019 and Epi Info (CDC Atlanta version 7.2.4.0).
Most of the data was expressed in percentages while
difference was statistically analysed using the chi square test
wherever applicable.
Results
The study included 100 patients with age range from 20 to 78
years (mean: 50.97~51 years ±14 years) with majority being
male (66%) while females comprised only a third of the study
population (34%).
Table 1: Description of Age of subjects
Subjects Total Mean Var Std Dev Min 25% Median 75% Max Mode
Age 100 5097 50.97 196.9587 14.0342 20 43 52 58.5 78 53
The overall prevalence of spinal degenerative findings in
descending order of frequency was disc degeneration
(commonest manifestation seen in N=100; 100%) followed by
nerve root compression (74%), spinal canal stenosis (67%),
disc herniation (64%), facetal arthropathy (41%), bulging
discs (38%) and ligamentum flavum hypertrophy (34%).
Modic type endplate degenerative changes (31%) were the
least common finding of this spectrum.
Table 2: Age-wise Distribution of Imaging Spectrum of Degenerative Disease of the Lumbosacral Spine
Age Group→ 20-39years n=21 40-59years n=56 60-79years n=23 Total n=100 p value of
Chi-square
tests Degenerative Finding Spectrum ↓
Number of
patients %
Number of
patients %
Number of
patients %
Number of
patients %
Disc Degeneration 21 100 56 100 23 100 100 100 1
Modic Changes 2 9.5 18 32.1 11 47.8 31 31 0.0223*
Disc Bulge 9 42.9 21 37.5 8 34.8 38 38 0.8533
Disc Herniation 10 47.6 34 60.7 20 87.0 64 64 0.0186*
Central Spinal Canal Stenosis 10 47.6 37 66.1 20 87.0 67 67 0.0209*
Nerve Root Compression 12 57.1 41 73.2 21 91.3 74 74 0.0351*
Facetal Arthropathy 0 0 18 32.1 23 100 41 41 <0.0001*
Ligamentum Flavum Hypertrophy 0 0 11 19.6 23 100 34 34 <0.0001*
* Statistically Significant
The overall prevalence as well as severity of Spinal
Degenerative Disease was directly proportional to advancing
age with advanced degenerative changes seen in all patients
above 60 years of age and was statistically significant.
Bulging discs were an exception with a higher prevalence in
the relatively younger age group but this difference was not
statistically significant.
The overall prevalence as well as more severe manifestations
of Spinal Degenerative Disease were more frequently
observed among males but this difference was not statistically
significant.
Table 3: Gender - wise Distribution of Imaging Spectrum of Degenerative Disease of the Lumbosacral Spine
Gender→ Males n=66 Females n=34 Total n=100 p value of
Chi-square
tests Degenerative Disease Spectrum ↓
Number of
patients %
Number of
patients %
Number of
patients %
Disc degeneration 66 100 34 100 100 100 1
Modic Changes 23 34.85 8 23.53 31 31 0.246
Disc bulge 24 36.36 14 41.18 38 38 0.639
Disc herniation 45 68.18 19 55.88 64 64 0.225
Canal stenosis 45 68.18 22 64.71 67 67 0.727
Nerve root compression 53 80.30 22 64.71 75 75 0.088
Facetal Arthropathy 31 46.97 10 29.41 41 41 0.090
Ligamentum Flavum Hypertrophy 25 37.88 9 26.47 34 34 0.254
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International Journal of Orthopaedics Sciences www.orthopaper.com Disc degeneration was the most frequent finding (N=100;
100%) with L4-L5 Disc being the single most commonly
affected level (72%). Multilevel involvement was more
frequent in the older subjects. The occurrence of these
changes in the younger patients was likely due to repetitive
microtrauma ascribed to bad posture and physical loading.
This was in consonance with similar studies carried out in the
past [4, 5].
Disc herniations were seen in majority of patients (64%) with
males having higher prevalence than females but was
statistically not significant. Also, pertinent to note is the fact
that (though not statistically significant) while disc bulges
were more frequently encountered in the younger subjects (in
20-39 years group); the herniations were more frequently
encountered in the older individuals. Overall, the vast
majority of the herniations (95%) were protrusions while a
minority (5%) were extrusions. Among these the
posterocentral & paracentral were the most common zones
(combined 91%) while exclusively foraminal and extra-
foraminal were far less common (7% & 2% respectively).
Central Spinal Canal Stenosis of varying degrees (Borenstein
et al. grading) [6] was invariably associated in all cases with
posterocentral and paracentral herniations as well as in those
with significant posterior disc bulges.
Nerve root compression correlated directly with more severe
disc herniations/protrusions as well as prominent posterior
bulging discs; with additional worsening effect due to
coexistent facetal arthropathy and ligamentum flavum
hypertrophy at the respective discal level wherever present.
Traversing nerve roots were more frequently compressed due
to posterocentral and paracentral herniations while exiting
nerve root compression was associated more with foraminal
& extra-foraminal zone herniations. Exiting nerve root
compression correlated well with all cases referred with
radiculopathy/ sciatica.
The presence as well as severity of Facetal Arthropathy as
well as Ligamentum Flavum Hypertrophy exhibited direct
correlation with advancing age (both seen to varying degrees
in 100% patients more than 60 years of age) with L4-L5
intervertebral level being the single most commonly involved
level irrespective of age and sex of the study subject.
Discussion: The MRI findings were analysed in all 100
patients with features of Degenerative Disease of the
Lumbosacral Spine alone without any comorbidities in
accordance with the inclusion and exclusion criteria. All the
acquired views and sequences were analysed and observations
compiled methodically into age & sex-based as well as
frequency-based categories.
The most frequent as well as severe changes were consistently
observed at the L4-L5 level irrespective of age and sex of the
study participant. This was explainable due to this level of the
Lumbar Spine being more prone to weight bearing and
resultant repetitive microtrauma related changes similar to
previously done studies by Ong et al. [5].
Disc Degeneration of varying degrees was the commonest
MRI correlate [4, 5, 7-10] in all these cases across all categories
seen at single/ few/ multiple vertebral levels in all cases.
However, the disc bulges were seen to be more frequent
among the younger subjects while herniations were more
frequently encountered in the elderly.
The Discal Herniations were categorised as per the Combined
North American Task Force Society Recommendations (11)
and the vast majority of these were protrusions with
extrusions seen in the minority of individuals. Two among
these exhibited Sequestrated discs with migration (one each
with the cranial and caudal respectively).
Case 1: 29 years F: T2 TSE SAG & AXIAL Lumbosacral Spine: L5-S1 disc: Single level involvement with broad-based posterocentral
herniation (yellow curve), midline annular fissure (red arrows) with compression of thecal sac & bilateral traversing nerve roots
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Case 2 & 3: A: 40years F: T2 TSE AXIAL L5-S1 Disc: Degenerated Disc with Broad-based Posterocentral Herniation causing compression of
thecal sac & impingement of right traversing nerve root
B: 36years M: T2 TSE AXIAL: Left Paracentral Herniation causing compression of Thecal Sac & left traversing nerve root
Spinal Central Canal Stenosis of varying degrees was
uniformly seen in all cases with discal herniations of the
posterocentral and paracentral zones as well as in those with
significant posterior disc bulges with no significant sex-
related variation in the study group as a whole. This was in
agreement with similar observations noted in the study by
Shobeiri et al. [12]
Nerve Root Compression was invariably observed in those
with the clinical profile of Sciatica with its prevalence
independent of the sex but directly proportional to the age of
the scanned subject. L4-L5 level was the most frequently
affected level in contrast to the L5-S1 level encountered in the
study by Shobeiri et al. [12]
Case 4: 43years F: A: T2 TSE SAG LS Spine: Grade 1 Retrolisthesis L4 over L5; L4-L5 reduced disc height; L3-L4 & L4-L5 posterior disc
herniations causing marked compression / near complete obliteration of Thecal sac; B: Myelogram Images: Near complete cut off of Thecal Sac
corresponding to herniating discs
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Case 5: 55years F: A: T2 TSE SAG LS Spine : Lumbosacral Transitional Vertebra (Sacralization of L5) (as labelled) with Multilevel Advanced
Spinal Degenerative Disease; B:L2-L3 : Diffuse asymmetric circumferential disc bulge with marked compression of Thecal Sac & Bilateral
Traversing & Exiting Nerve roots; C: Large extruded disc fragment with superior migration on right side; D: Modic Type II endplate
degenerative changes
Ligamentum Flavum Hypertrophy [13] as well as Facetal
Arthropathy [14] were increasingly encountered in the older
individuals with resultant aggravation of the pre-existing
discogenic central spinal canal stenosis; similar to previous
such studies.
Case 6: 58 year F: A: T2 TSE SAG Screening Whole Spine: Multilevel Disc-osteophyte complexes causing marked cervical central canal
stenosis with altered cord signal intensity consistent with Compressive Myelopathy; B: T2 TSE AXIAL L4-L5 Disc level: Bilateral Facetal
Arthropathy; C: T1 TSE AXIAL: Bilateral Ligamentum Flavum Hypertrophy
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International Journal of Orthopaedics Sciences www.orthopaper.com Modic Type End Plate Degenerative changes were the least
frequently encountered finding but exhibited a definite age
proportional trend similar to findings by Kuisma et al. [15]
This was likely ascribed to physiological ageing related
changes in the older study subjects. Also, to be noted is the
observation that Type II changes were more frequently seen
in close agreement with the study by Kuisma et al. [15]
The additional Whole Spine Sagittal Screening image enabled
detection of coexistent Cervical Spine Degenerative Disease
(in 92% cases with two of these with MRI features of
Compressive Myelopathy Cervical Cord) as well as Dorsal
Spine Degenerative disease (in 25% cases). There was also
the additional benefit of detection and confirmation of
Congenital Spinal Anomalies (N=12; 12%) viz. Lumbosacral
Transitional Vertebra (5 cases) and Congenital Block
Vertebra (2 cases), Persistent Ventriculus Terminalis (1 case)
and Filar Lipoma (3 cases).
Case 7: A: 63years M: T1 TSE SAG Lumbosacral Spine: Lumbarization of L1 with well-formed S1-S2 disc (*); Vacuum Disc Phenomenon L5-
S1 disc (white arrow)
Case 8: 41years M: B: T1 TSE SAG: Long segment Filar Lipoma; C: T1 TSE AXIAL: Filar Lipoma
Case 9: A: 53years M: T2 TSE WHOLE SPINE SAG: Multilevel degenerative discs Dorsal spine but no frank herniation
Case 10: 72 years M: B: T2 TSE SAG: Pre-existing congenital bony spinal canal stenosis aggravated by multi-level spinal degenerative disease
(Schmorl’s nodes and Retrolisthesis L5 over S1; C: Posteriorly herniating degenerated dorsal discs causing thecal sac compression
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Case 11: 48 years M :A: T2 TSE SAG Screening Whole Spine : Multilevel Disc-osteophyte complexes causing marked Cervical central canal
stenosis Most marked C4-C5 & C5-C6 intervertebral disc levels with resultant Compressive Myelopathy leading to Syrinx formation; B: T2
TSE AXIAL L3-L4 disc Level : Marked diffuse symmetric circumferential disc bulge causing severe bilateral foraminal compromise &
compression of thecal sac & bilateral traversing nerve roots
This study also had an unforeseen spinoff by way of enabling
the detection of hitherto unsuspected and undiagnosed
ancillary extra-spinal conditions (N=11; 11%) viz. Renal (5
patients in all; one case each with Right Renal Caudal Ectopia
with Aberrant Vascular Anatomy, Unilateral Renal Hydatid
Disease, Unilateral Angiomyolipoma, Autosomal Dominant
Polycystic Kidney Disease and Giant Exophytic Renal
Cortical Cyst) ; Adrenal (one case with unilateral lipomatous
mass), Uterine (4 cases; one with Diffuse Uterine
Adenomyosis and three with Fibroids) as well as
Hepatomegaly (1 case)
Incidentally detected Non-Spinal Conditions: A: Hepatomegaly; B: Uterine intramural Fibroid; C: Correlative NCCT Axial section: Renal
Angiomyolipoma: D&E: Bilateral Autosomal Dominant Polycystic Kidney Disease: Bilateral Renal & Hepatic cysts
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Incidentally detected Non-Spinal Condition: Left Renal Hydatid Disease
Incidentally detected Non-Spinal Conditions: Renal positional anomaly with aberrant vascular anatomy: Orthotopic Left Kidney (A); Right
Renal Caudal Ectopia (B); Right Kidney with dual arterial supply (1 & 2) from Abdominal Aorta (C&D); Left Kidney with Dual Venous
Drainage into Inferior Vena Cava (caudal is retroaortic) (E&F)
Conclusion: MRI has a key role in the accurate and
comprehensive evaluation of Degenerative Disease of the
Lumbosacral Spine. Its ability to assess the Functional Spinal
Unit inclusive of the normal anatomy, discal composition &
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International Journal of Orthopaedics Sciences www.orthopaper.com architecture and central spinal canal stenosis all justify and
approve of its indispensable role in the radiological workup of
such cases. It is hence highly recommended to be carried out
in all MRI compatible and safe scenarios in patients with low
back pain irrespective of the presence or absence of
radiculopathy and /or neurological symptoms.
Acknowledgements
We would like to express our gratitude to the MRI Division
Radiographers viz. S. Jarnail Singh, Mr. Sanjeev Kumar & S.
Hardeep Singh for their sincere and dedicated efforts during
the conduct of the present study.
Source of support: Nil
Conflict of interest: None
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